An exit meeting is held with the claims director to clarify our findings and insure the accuracy of our results. The final report is formulated and forwarded to the client.
A description and appraisal of on-site review and general narrative.
Itemization of erroneous claims with detailed explanation.
A complete statistical summary.
Evaluate the effectiveness of the administrative process.
Assess, based on a limited number of claims, the accuracy and consistency of claims processing.
Document control or processing errors noted during the course of performing the aforementioned procedures.
Measure turnaround time.
Assess claim processor compliance with cost containment program requirements.
Perform a general operational review to identify area of administrative efficiency that the TPA may wish to implement.
Identify areas for potential improvement.
Obtain and read a summary of the provision of the Plan.
Meet with the TPA claims administration and discuss the claims administration operations.
Select a random sample of 450 claims per audit paid processed during the selected period to determine adherence to the plan's provisions. The sample is selected by a formulated listing provided to us by the TPA. The number of sample claims selected is based on a confidence level of 95% and a precision limit of 5%.